5.3 Children not brought to appointments or meetings that relate to their welfare, care or health.

Within the context of this guidance, a meeting or appointment is any such that relates to the welfare, care and health of a child, including but not limited to; medical appointments, dental appointments, home visits, meetings/appointments called by children’s service etc. 

Children rely on their parents to take them to meetings or appointments that relate to their welfare, care or health, and as a result they are sometimes not taken to them. This may mean that a practitioner may record them as having ‘not attended’, but it was because they were not brought.

Practitioners should use “Was Not Brought (WNB)” rather than “Did Not Attend” for recording or noting the non-attendance of children who are reliant on someone else to take them to a meeting or appointment. The phrase “Did Not Attend” implies that the child is responsible for not attending. Recording “Was Not Brought (WNB)” is a more accurate representation of the situation and enables a practitioner to consider the reasons why a child was not brought to a meeting or appointment, the implications for them not having been brought, and assess the potential risks or safeguarding concerns for them, especially if there is a repeat pattern of non-attendance.

Repeated cancelled and rescheduled appointments should also be treated with some curiosity and may occasionally indicate potential harm. This could be a sign of disguised compliance. Disguised Compliance involves a parent or carer giving the appearance of engagement, they may cancel appointments frequently at the last minute, or after a period of non-engagement may attend appointments to reduce professionals’ concerns.

Nottingham City Council, NHS Nottingham City ICB and the Safeguarding Partnership jointly commissioned a video animation to encourage practitioners to identify children as 'Was Not Brought' as opposed to 'Did Not Attend' when referring to them not being presented at medical appointments. You can watch this here - Rethinking ‘Did Not Attend’ - YouTube

Child Safeguarding Practice Reviews (and previously, Serious Case Reviews), both nationally and regionally, have featured 'missed' appointments as a precursor to serious child abuse and even child death.

Children not being brought to their appointments or meetings is a safeguarding concern. Non-attendance at or repeated cancellations of appointments and lack of access to the child on visits are indicators that should increase concern about the child's welfare. Missed health appointments in particular are a significant risk factor. All NHS providers should have policies for the management of children not brought to health care appointments. If you work in a health setting you should refer to your Trust’s ‘Was not brought’ policies and procedures, or talk to your designated safeguarding lead-  Local Contact Details

When non-attendance relates to the parent or carer, particularly when mental illness, domestic abuse, learning difficulties or substance misuse is present; practitioners should ask themselves "What does this mean for the child's care and safety? What do I need to do?"

It is important to understand what factors may influence whether the parent/carer attends or continues to attend meetings, appointments and sessions which relate to their child’s welfare, care or health.

 Engagement is likely to improve when:

•  Parents are given enough information about what is happening, why and what is expected from them
• - Parents and professionals have a shared understanding of what needs to change in the family
• Parents are confident their views and experiences are valued; practitioners should consider their working style and use of power, and how this will be perceived.

Consider what influences a parent/carer to not attend a meeting/appointment. It may not always be an indicator of non-compliance.

• Forgetfulness - parents forget or don't prioritise attending because they don't understand the significance of not going
• Fear & Anxiety - it can be intimidating for parents who may already lack confidence and esteem to meet with practitioners
• Logistics - house moves, letters going astray, poor communication, competing appointments at diverse locations, on consecutive days etc.

A child ‘in need’ is one where the Local Authority have completed an assessment which concludes that they would benefit from support, and they meet the definition of a Child in Need as set out by the Children Act 1989.

If parents or a young person of age of understanding, (particularly those aged 16 or 17) refuse the support offered or do not attend assessments/meetings arranged under the proposed plan there will need to be further consideration as to the potential impact upon the child.

In the first instance discussions should take place with the parents and young person regarding their concerns and reasons for refusal, to try and provide reassurance/further clarification to obtain consent. If a suitable alternative source of support is proposed by the parent or young person that will adequately meet the identified need, this should be given due consideration. The social worker, in conjunction with other agencies involved, will need to identify how this will be monitored and further discussed with Children’s Service’s if this intervention is either not subsequently sourced, or ceases prior to the desired outcome being achieved.

If there is no suitable alternative support identified and consent to provide services under S.17 is refused,  see sections 5.3.17 - 5.3.22,  below.

If a child doesn’t attend an appointment or meeting, consider:

•  Are they reliant on someone else to make and/or take them to appointments or meetings?
• What are the implications of them not attending the appointment or meeting? Are they missing needed medication or assessment, being denied the opportunity of inputting into a planned review, not being part of a discussion about their care, health and wellbeing. 
• Is this a one off, or is there is a repeat pattern? Is disguised compliance a concern? Use chronologies to record the child and parents attendance at appointments, meetings, assessments etc. to evaluate attendance patterns.
• What could be the reason for their non-attendance? Be professionally curious. Is it forgetfulness, fear and anxiety, logistics or are there any other factors to consider, like coercion and control, or neglect.

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Record or note the non-attendance as “Was Not Brought (WNB)”

 Within the notes state:

• that the child was reliant on someone else to bring them to the meeting
• any impact or safeguarding concern their non-attendance may have raised
• if this was the first or repeat non-attendance and identify any emerging patterns
• the action you have taken in response

Discuss, ideally by phone, episodes of non-attendance with colleagues and any other relevant agencies, inlcuding their paediatrician (community or hospital) and/or GP and children’s services, if the child is looked after, or has a child in need or child protection plan) Consider the following factors:

•  Is the child a child in need (CIN) or already on a child protection plan (CPP)
• Is the child looked after (child in care)
• What is the potential impact of non-attendance on child’s care, health and wellbeing?
• Are there known issues that may affect the adult to parent/care appropriately for the child (e.g. substance or alcohol misuse, chronic health problems, social situations, domestic violence, learning disability)?
• Are there more than expected attendances at Outpatient, A&E or Urgent care Centres?

 Contact the child's parent/carer to:

• enquire why they did not come to the appointment or meeting
• encourage them to rearrange, being clear about why it is important to attend, what the benefits are, and any risks to the child’s care, health or wellbeing as a result of non-attendance
• discuss with them any barriers which may have impacted on them attending
• identify and arrange support to attend future meetings if needed. Encourage them to set up reminders in their phone, using a diary, provide them with a list of all the key dates, times and venues, discuss practical support with transport etc.

Persevere. If contact cannot be made, or if a further meeting cannot be agreed, do not discontinue the service or appointment without discussion with your designated (in NHS this is a specific role at a senior level, in health trusts this stage involves Named Doctors/nurses) safeguarding professional and consideration to your agency’s own attendance or ‘was not brought’ policies.

Escalate. If you have concerns about children not being brought to their appointments or meetings,  then a referral to children’s services must be made – see Making a Referral . It is important that the referral to Children Service’s specifies the concerns and the likely impact on the child of not receiving the appropriate care. For a child who WNB to a hospital appointment the hospital’s own policy/procedure will also apply. An immediate referral should be made if it is established that urgent medical attention has not been sought or delayed.

If there is no suitable alternative support identified and consent to provide services under S.17 is refused, the social worker and pod/team manager will need to discuss and consider the impact for the child - both in the short term and the long term, and the manager must record the rationale for the Management Decision.

Refusing to consent to support under S17 maybe a safeguarding issue in its own right.

Analysis within the assessment should set out the implications of not receiving the support identified and the focus should be on ‘will this benefit the child or is it a need?’

If the child would benefit from the support but the impact of not receiving this support will not be significant, then the refusal has to be accepted and recorded. If it is a need and “their health or development is likely to be significantly impaired, or further impaired without the provision for him/her of such services” then consideration should be given to undertaking an assessment under S.47, see more Section 47 Enquiries . Decisions should be clearly recorded on the child’s file including the analysis behind the decision.

Any closure record should include the risks that have not been addressed and the reason being not wanting to engage under S17. This then allows this to be included in the analysis of future referrals.

It is important that good communication and information sharing takes place with relevant professionals when there are concerns that a child was not brought to appointments and meetings, including the actions taken to ascertain the reasons for this.